Trauma (chemical)

The CMGs are guidelines on the diagnosis and management of a range of common and rare, but important, eye conditions that present with varying frequency in primary and first contact care.

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Aetiology

The incidence of chemical injuries to the eye has been reported to be 10.7 per 100,000 population, representing an estimated 10% of ocular trauma treated in emergency departments. Most patients are males aged 16–25 years.

A wide variety of chemicals can be responsible for ocular injury, including:
Alkalis, such as:

  • ammonia compounds (household cleaners, fertiliser)
  • sodium hydroxide (drain and oven cleaners)
  • lime, i.e. calcium hydroxide (cement, plaster)

(NB alkalis cause liquefactive necrosis and readily penetrate the eye)

Acids, such as:

  • sulphuric (car batteries)
  • hydrofluoric (glass etching)
  • hydrochloric (>25% is corrosive)
  • glacial acetic (wart, verruca treatment)
  • citric (limescale removal)

(NB acids cause coagulative necrosis which impedes penetration of the eye)

Detergents, such as:

  • free chlorine liberating compounds including sodium hypochlorite (bleach)

Solvents, such as:

  • paint thinners
  • petrol
  • nail varnish remover

Fixatives, such as:

  • formaldehyde
  • glutaraldehyde

Contact lens solutions, including hydrogen peroxide; in clinics, tonometer disinfection fluids
Pepper spray, tear gases (CS, CN, CR)
Cyano-acrylate adhesive (superglue) – tube can be confused with eye ointment

Predisposing factors

  • Domestic accidents, DIY injuries
  • Industrial injuries
  • Assault
  • Riot control
  • Warfare

Symptoms

  • Immediate pain, redness, epiphora
  • Visual loss
  • Severe chemical trauma may be relatively pain free (damage to superficial nerves)

Signs

  • Burns to eyelids and surrounding skin
  • Particulate matter under lid (evert to examine)
  • Conjunctival chemosis and hyperaemia
  • Limbal and conjunctival blanching (cessation of blood flow in superficial vessels; may indicate poor prognosis)
  • Corneal epithelial defects ranging from superficial punctate keratitis through focal epithelial loss to sloughing of the entire epithelium
  • Corneal oedema and opacification in severe cases (may prevent view of anterior chamber, iris, lens or beyond)
  • Raised IOP

Various chemical trauma classification systems exist, e.g. those of Roper-Hall and Dua and the ILSI classification. Each of these establishes limbal ischaemia as dividing mild from more severe trauma

Differential diagnosis

  • Corneal abrasion
  • Other causes of acute red eye; history should aid the diagnosis

Management by optometrist

Practitioners should recognise their limitations and where necessary seek further advice or refer the patient elsewhere

Non pharmacological

Immediate management

  • Irrigation should begin immediately at the scene of the accident
    with any non-toxic liquid (e.g. tap water
  • On presentation to clinical care, the patient should receive
    copious prolonged irrigation of the eyes with sterile normal saline
    (at least one litre); if not immediately available, use tap water
  • Irrigate for 15-30 min (with intermittent topical anaesthetic if required) or until pH between 7 and 8 (normal value 7.4, range 7.3 – 7.7): to measure, cease irrigation, wait for 1 min, apply universal indicator paper to fornix
  • When pH normal, check again after additional 30 min
  • Remove any particulate matter, sweeping the fornices with a moistened cotton bud
  • Ascertain which chemical caused the injury
  • Check VA (important even if pain and/or swollen lids make this difficult)
  • Contact lens solution accidents do not require irrigation, but advise no contact lens wear until after satisfactory review

(GRADE*: Level of evidence=moderate, Strength of recommendation=strong)

Pharmacological
  • In severe cases (i.e. where there is limbal ischaemia or loss of corneal transparency), no pharmacological intervention (immediate referral)
  • In mild cases, e.g. contact lens solution accidents, give ocular lubricants for symptomatic relief
  • For pain or photophobia, advise systemic analgesia and darkened room

(GRADE*: Level of evidence=low, Strength of recommendation=strong)
 

Management category

In severe cases:
A2: first aid measures and immediate referral to A and E.
Emphasise to the patient the urgency of the condition and instruct them to attend the local hospital eye department or hospital A & E the same day, explaining that you will leave a message so that they are expected. Telephone the department to explain what you have done, preferably leaving your message with a doctor or other health care professional.
In mild cases:
B2: alleviation/palliation (normally no referral)

Possible management by ophthalmologist

  • Further irrigation
  • Admission to hospital where necessary
  • Treatment with topical antibiotic, topical steroid, systemic ascorbic acid, topical sodium citrate, systemic acetazolamide if IOP raised, other drugs
  • Surgical rehabilitation, e.g. amniotic membrane graft, limbal stem cell transplantation

Evidence base

*GRADE: Grading of Recommendations Assessment, Development and Evaluation (see www.gradeworkinggroup.org)
 

Sources of evidence

Bagley DM, Casterton PL, Dressler WE, Edelhauser HF, Kruszewski FH, McCulley JP, Nussenblatt RB, Osborne R, Rothenstein A, Stitzel KA, Thomas K, Ward SL. Proposed new classification scheme for chemical injury to the human eye. Regul Toxicol Pharmacol. 2006;45(2):206-13

Blackburn J, Levitan EB, MacLennan PA, Owsley C, McGwin G Jr. The epidemiology of chemical eye injuries. Curr Eye Res. 2012;37(9):787-93

Chau JP, Lee DT, Lo SH. A systematic review of methods of eye irrigation for adults and children with ocular chemical burns. Worldviews Evid Based Nurs. 2012;9(3):129-38

Dua HS, King AJ, Joseph A. A new classification of ocular surface burns. Br J Ophthalmol. 2001;85(11):1379-83

Ikeda N, Hayasaka S, Hayasaka Y, Watanabe K. Alkali burns of the eye: effect of immediate copious irrigation with tap water on their severity. Ophthalmologica. 2006;220(4):225-8

Schrage NF, Langefeld S, Zschocke J, Kuckelkorn R, Redbrake C, Reim M. Eye burns: an emergency and continuing problem. Burns. 2000;26(8):689-99

Lay summary

A variety of chemicals, coming into accidental or deliberate contact with the eye, can damage it. These include alkalis, acids, detergents, solvents, certain contact lens solutions and pepper spray or tear gas. Generally the damage is greatest with alkalis such as ammonia, found in some household cleaners, and sodium hydroxide, present in drain and oven cleaners, as these chemicals pass easily through the outer coat of the eye. Chemical injuries can occur in assaults, and in work, DIY or household accidents, also in riot control and warfare situations.

The result of a chemical injury to the eye is usually pain, redness and watering of the eye, all of which may be severe, and there may be loss of vision also. The task of the optometrist is to quickly judge the nature and extent of the injury and then, in all but mild cases, to flush the eye with large amounts of saline solution in an attempt to wash away the alkali or acid that may have caused the injury.

After this first aid, the optometrist will arrange for the ophthalmologist to see the patient as soon as possible on the same day. Depending on the severity of the injury, the ophthalmologist may admit the patient to hospital for further intensive treatment.

 

Trauma (chemical)
Version 10
Date of search 17.08.17
Date of revision 30.01.18 
Date of publication 09.05.18
Date for review 16.08.19
© College of Optometrists

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